Data sources

Studies were identified by searching the Cochrane Tobacco Addiction Review Group specialised register (which includes studies
identified from Medline, EMBASE/Excerpta Medica, and PsycLIT, and by hand searches of specialist journals, conference proceedings,
and bibliographies) using the terms nurse or health visitor. CINAHL was also searched from 1983 using the terms nursing, smoking
cessation, and intervention.

Study selection

Randomised trials were selected if they evaluated the effectiveness of nurse delivered smoking cessation interventions (defined
as provision of advice or other information and strategies to help patients stop smoking) for adults; had ≥2 treatment groups;
and had ≥6 months of follow up. Studies were excluded if the sample included pregnant women, if they compared advice alone
with advice plus nicotine replacement therapy, or if no outcome data were provided on smoking cessation rates.

Data extraction

Data were extracted on study setting and design, sample size, definition of a smoker, description of the intervention and
its intensity, outcomes, and biochemical validation. Main outcome was smoking cessation, defined using the strictest available
criteria for abstinence (eg, sustained cessation rather than point prevalence). Studies were assessed for quality and rated
for efforts to control for selection bias.

Main results

19 studies met the selection criteria; 17 involved patients from hospitals or primary care settings and 18 involved adults
with diagnosed health problems. 14 studies reported smoking cessation validated by biochemical analysis of body fluids or
expired carbon monoxide. Meta-analysis included 15 studies (n=7912) and was done on an intention to treat basis. At longest
follow up, patients who received advice from a nurse were more likely to stop smoking than those who received usual care (table).

Conclusion

Commentary

Associate Professor, School of Nursing University of Ottawa Ottawa, Ontario, Canada

This meta-analysis by Rice and Stead provides a review of smoking cessation interventions delivered by nurses to patients
in hospital and outpatient settings. The findings lend support for smoking cessation counselling by nurses but provide little
direction for choosing the optimal set of strategies for a smoking cessation programme (eg, self help manuals, individual
counselling, or telephone follow up).

The authors classified cessation strategies into low and high intensity interventions based primarily on the duration of the
intervention. Surprisingly, they observed that low intensity rather than high intensity smoking cessation strategies led to
successful cessation. A review of the high intensity interventions indicates that many of them required >1 visit by a patient
to a healthcare setting (eg, multiple sessions over time) or involved group interventions. It is not possible to determine
whether these factors produced the differential effect of high versus low intensity interventions. Furthermore, the meta-analysis
did not take into account other factors known to influence the effect of cessation interventions, including patient characteristics
(eg, readiness to change behaviour, perceived risk of smoking, and type of events triggering behaviour change); contextual
factors (eg, partner and family support for cessation, and social norms); and features of the intervention (eg, individual
versus group counselling, and the theoretical model underlying the intervention).

The focus of this meta-analysis was the nurse as a vehicle for providing the intervention. A previous review showed that smoking
cessation interventions provided by several healthcare professionals have a stronger effect than interventions delivered by
a single provider.1 Nurses should therefore strive to ensure that all members of the healthcare team provide a consistent message about the importance
of smoking cessation.

A central question raised by this review is whether smoking cessation counselling by nurses simply provides a means of reaching
a larger number of patients, or suggests an opportunity to improve smoking cessation interventions. It is perhaps time to
capitalise on the strengths nurses bring to patient care situations and use these to enhance cessation efforts. This might
lead to interventions that are timed to better reflect patients' readiness to change, address contextual influences for individual
lifestyle choices, and involve partners and other family members in supporting smoking cessation efforts.